multiple_pregnancy_medical_student_ppt_radha_apr_2011.ppt

7/23/2019 multiple_pregnancy_medical_student_ppt_radha_apr_2011.ppt

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Multifetal

PregnancyRadha VenkatakrishnanClinical LecturerWarwick Medical School



•Incidence :•

Monozygotic twins - 4/!!! "irths•#izygotic twins $ %/&rds' race' age'assisted conce(tion• )ri(lets $ in *!!! to !'!!! "irths•+uadru(lets $ in ,!!'!!! "irths

• l.ost eery .aternal and o"stetric

(ro"le. occurs .ore 0re1uently in .ulti(le 2regnancy

• 2erinatal .ortality rate in twins is 3 ti.es

higher and







•ygosity re0ers to the ty(e o0conce(tion

•Chorionicity denotes the ty(e o0(lacentation

•Chorionicity rather than zygositydeter.ines out

outco.e

ygosity and Chorionicity



Mechanism of dizygotic

twinning





• Fertilization of asingle ovum

• Similar sex

• Geneticallyidentical

• Fertilization of 2separate ova







Monochorionic twins

• Within 72 hours!"#$2%&

•$#" days later '(#7(%&

http://2.bp.blogspot.com/_-h4yJp9xum0/SjFpZhJQ0cI/AAAAAAAAAP8/ZHjfO_2Uosw/s1600-h/TwinMD.gif

http://4.bp.blogspot.com/_-h4yJp9xum0/SjFn2mlubEI/AAAAAAAAAPs/rRJ6R6ukwNs/s1600-h/TwinDDF.gif



Monochorionic twins

•"#!2 days later !#2%& •!2#!$ days later ()*%&

http://4.bp.blogspot.com/_-h4yJp9xum0/SjFqgqGKMVI/AAAAAAAAAQE/A8RUBVGnAGM/s1600-h/TwinMM.gif



Maternal res(onses

Cardiac out(ut' 56R and renal "lood7ow 2las.a olu.e "y /& 8 singletons Red cell .ass &!! .l 8 singletons

9e.atocrit and he.oglo"in Iron stores in 4! o0 wo.en with

twins

Multi(le (regnancy



#iagnosis

2atient (ro;le:

• <tiological 0actors:

– (ositie (ast history and 0a.ily history

s(ecially .aternal' race' age – ssisted re(roductie technology

• <arly (regnancy:

–

9y(ere.esis' e=cessie weight gain – .inor co.(lications o0 (regnancy such as

"ackache' ede.a' aricose eins'

he.orrhoids' striae' etc



2hysical signs

• 5eneral: – 2allor' weight gain' e=cessie (edal ede.a/

aricose eins – 2regnancy Induced 9y(ertension>2I9? and 2re-

ecla.(sia >3-!ti.es .ore?

• "do.inal: – Size 8 #ate es(ecially in .id(regnancy – Multi(le 0etal (arts – uscultation o0 69S: – % di@erent recordings "y % o"serers and a

di@erence 8 ! "(.



#i@erential diagnosis

• <leation o0 the uterus "y a distended

"ladder• Inaccurate .enstrual history• 9ydra.nios• 9ydatidi0or. .ole

• Aterine ;"roids• closely attached adne=al .ass• 6etal .acroso.ia >late in (regnancy?



Altrasonogra(hy

• #etect .ulti0etal gestation BB"e0ore %, weeks•

Con;r. 0etal nu."er % sacs or%0etal heads in % (er(endicular (lanesD• #iagnose ty(e and (resentation and(osition and relation to each other•

<=clude congenital a"nor.alities/conEoint twin





Maternal co.(lications

• Sy.(to.s $ hy(ere.esis' aches and(ains o0 (regnancy worsen

• 9y(ertensie disease o0 (regnancy•

2reter. deliery• 2re.ature ru(ture o0 .e."ranes• 2olyhydra.nios• 2lacenta (raeia•

Mal(resentation• #eliery co.(lications >o(eratie deliery'

(lacental a"ru(tion' cord accidents?• 2ost(artu. he.orrhage' de(ression



6etal co.(lications

• S(ontaneous early (regnancy loss• 2re.aturity

• Intra-uterine growth restriction• Cere"ral (alsy - related to

gestational age' & ti.es in twins' 8! ti.es in tri(lets

• Intra(artu. trau.a• Monochorionic twins $ s(eci;c

co.(lications





ntenatal care

• Routine "ooking inestigations6olic acid su((le.entationane.ia $ treat i..ediately

Su((ort sy.(to.atically

• Serial growth scans :

#ichorionic :4 weekly 0ro. %4weeks

Monochorionic : % weekly 0ro. F

weeks-





Intra(artu. .anage.ent

•2resence o0 skilled o"stetrician'anesthetist and neonatologist aaila"le atdeliery•

Relia"le intraenous access•Cardiotocogra(h with dual .onitoringca(a"ility•2orta"le ultrasound scanner

•#eliery "ed with lithoto.y stirru(s•G"stetric 0orce(s or acuu. a((aratus• actie .anage.ent o0 third stage:Aterotonics•I..ediate aaila"ility o0 "lood











Monochorionic Monoa.niotic

twins

•& - % = (erinatal .ortality•! = cere"ral necrotic lesions

• o0 .onozygotic twins are.onoa.nionic

•2erinatal .ortality rate o0 &!-3!'largely relates to a risk o0intrauterine death "e0ore &% weeks

•







)win-)win )rans0usion Syndro.e

•Incidence : 4 - %! o0 MC twins

•It is characterised "y an i."alance o0 "lood7ow "etween the twins

•

3 - %! o0 (erinatal deaths

•Antreated' (erinatal loss rates in the .id-tri.ester

>F! - !!?





Large olu.e

a.nioreduction



.niotic

Se(tosto.y



6etosco(ic Laser

"lation



#eliery "y Caesarean section

at &4 weeks



ConEoined twins or Sia.ese

twins

•nterior >thoraco(agus?

•2osterior >(ygo(agus?

•Ce(halic >cranio(agus?

•Caudal >ischio(agus?





Single intrauterine de.ise

•%-, o0 twins (regnancies

•

A( to %3 in MC twin (regnancy

• 2erinatal .or"idity and .ortality o0 thesuriing

co-twin - B (erinatal death - %4 haing serious long ter. se1uelae



)reat.ent o(tions

•Ho o(ti.al .anage.ent

•2ro.(t deliery -Iatrogenic (re.aturity

risks

•Conseratie treat.ent -Su"se1uenthandica(s

•Intrauterine interentions



9igh order .ulti(les

•2erinatal risk increases e=(onentially withincreasing

nu."er o0 0etuses

•Multi0etal (regnancy reduction >M62R? at! to % weeks should "e reco..ended 0or

1uadru(lets and higher .ulti(les

• )he situation with tri(lets is .orecontroersial



multiple_pregnancy_medical_student_ppt_radha_apr_2011.ppt

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